Background: Upadacitinib is a selective Janus kinase inhibitor approved for the management of ulcerative colitis and is under evaluation for the management of Crohn’s disease [CD] in Phase 3 clinical trials. Aims: Our goal was to describe our real-world experience with upadacitinib in CD. Methods: This is a two-centre retrospective cohort study of adult patients with moderate to severe CD on upadacitinib. The primary outcome was clinical response and remission as determined by stool frequency and abdominal pain scores. Secondary endpoints included endoscopic response and remission as determined by change in Simple Endoscopic Score for CD. Outcomes were assessed at 3 months after starting upadacitinib and at the patient’s most recent follow-up. We further evaluated adverse events and dose-related response. Results: A total of 45 CD patients received upadacitinib and were included in the safety analysis. Thirty-six patients received upadacitinib for CD, whereas nine received it for inflammatory arthritis [n = 8] or pyoderma [n = 1]. Thirty-three patients received upadacitinib for 3 months or longer and were included in the efficacy analysis. At the 3-month follow-up, 21 patients achieved clinical response [63.6%] and nine achieved clinical remission [27.2%]. At time of last follow-up, 23 patients had clinical response [69.7%], ten achieved clinical remission [30.3%] and four [28.6%] achieved endoscopic remission. Adverse events occurred in 12 patients [26.7%]. Two patients had a serious adverse event [4.5%] without associated mortality. Conclusion: In this real-world cohort of highly refractory CD patients, upadacitinib was effective in inducing remission and had an acceptable safety profile.

Background: Microscopic colitis (MC) is suspected to result from increased immune activity in gut mucosa. Immune checkpoint inhibitors (ICIs) treat cancer by activating the immune system, and further investigation is needed regarding their role in the development of MC. Methods: A retrospective case series investigated cases of endoscopically and histologically confirmed MC developing after administration of ICIs. Clinical notes and medication administration records were reviewed for demographics, symptom duration, and treatment response. Results: Nineteen cases of de novo MC were identified, with 95% of cases requiring steroid treatment, 53% presenting with hospitalization, and colitis-related mortality in 1 individual. Symptom onset occurred a median of 160 days after initiation of ICI therapy and 53 days after their most recent dose of therapy. Patients had a median of 125 days of symptoms, and ICI therapy was held in 70% of individuals due for treatment. Conclusions: MC can develop after ICI administration, and presents with severe symptoms, often requiring hospitalization and steroid treatment. In certain individuals this can require a prolonged treatment course of steroid therapy or immunomodulators. Individuals developing diarrhea after ICI therapy warrant thorough workup including endoscopy and rapid treatment initiation given the disease severity observed in this series.

LINKED CONTENT: This article is linked to Meserve et al paper. To view this article, visit https://doi.org/10.1111/apt.16217

Introduction: Glucagon-like peptide-1 (GLP-1) receptor agonists (GLP1RAs) are increasingly used to treat obesity and other metabolic conditions; however, they are known to inhibit gastrointestinal motility. Since gastrointestinal microbial overgrowth (MO) can arise in states of intestinal stasis, we sought to investigate the potential association between GLP1RA use and MO. Methods: We analyzed data from 99 patients prescribed GLP1RAs who subsequently underwent testing for MO via intestinal aspirate culture or glucose or lactulose breath tests. Results: Most patients had diabetes. Among patients who underwent culture, 76.2% tested positive for small intestinal bacterial overgrowth (SIBO) at a threshold of ≥10³ CFU/mL, with a significant association found between proton pump inhibitor (PPI) use and SIBO. At ≥10 ⁵ CFU/mL, 33.3% tested positive for SIBO, and neither PPI use nor surgical history was associated. Breath testing revealed a 30.6% positivity rate for MO, predominantly characterized by intestinal methanogen overgrowth (IMO). There was no association between control of diabetes and positive MO tests. Conclusion: GLP1RA use is associated with SIBO, although diabetes may be a confounder.

Patients with inflammatory bowel disease (IBD) frequently ask their providers for nutritional or dietary recommendations; however, providers are limited in both time and knowledge to adequately address their questions. In this single-center study, we sought to improve provider experiences with nutrition counseling for patients seen in a dedicated IBD clinic. To understand the current state, providers, including gastroenterology fellows, attendings, and advanced practice providers were surveyed regarding their experiences with nutritional recommendations in a dedicated IBD clinic. Following the pre-intervention survey, we worked with registered dieticians on how to address key concerns and developed an informational handout based upon current guidelines. After displaying handouts in clinical workspaces for 5 weeks, providers were surveyed again to evaluate their response. All 22 respondents (100%) in the pre-intervention survey either agreed or strongly agreed that IBD patients have unique nutritional requirements. A majority (72%) strongly agreed that the clinic would benefit from more access to dieticians. Additionally, 41% of providers either strongly disagreed or disagreed that they had enough time to address nutritional concerns. Post-intervention, 57% of respondents (8/14) reported that they found the handouts helpful. A significant number of providers reported improvement in their comfort level discussing nutrition and dietary recommendations with IBD patients, with tmean Likert score increasing from 3.5 to 4.1 (P = .01). In this quality improvement study, we identified key issues preventing providers from addressing patient desire for nutritional counseling and developed a novel awareness campaign that significantly improved provider confidence in discussing nutritional recommendations with their IBD patients.